Primary care is tanking. Job dissatisfaction is high, burnout is rampant, residents are voting with their feet in droves, and most primary care confabs have become sky-is-falling angst-a-thons.

Since many people identify me as “the guy who invented hospitalists” (to which my stock reply is “just like Al Gore invented the Internet”), I have had more than one person accuse me of being the cause of primary care’s declining popularity. I’ve always responded to this accusation (which, even if true, markedly overstates my influence – I can’t even get my kids to clean their rooms) with the following arguments:

Primary care was losing popularity before the hospitalist field took off – its decline really began when managed care, which artificially propped it up through gatekeeping (remember “I’m a primary care ophthalmologist!”), began receding in the mid-1990s;

The primary care physician (PCP) who depended on his/her hospital work for job satisfaction, CME, or to “rub shoulders with my colleagues” was hurting anyway – even when there are no hospitalists around, the average PCP now spends less than an hour a day in the hospital (usually before 8 am), down from three hours a day in 1980;

Surveys indicate reasonably high levels of PCP satisfaction with hospitalists, and many hospitalist programs have been formed to meet PCP demand. After being razzed by my primary care brethren at many of my hospitalist talks in the mid-90s, I discovered this trend when I received a phone call from a North Carolina hospital CEO in 1999. “We resisted hospitalists at first, ‘cause the PCPs didn’t like the idea,” he drawled. “Then I got a letter from one of our old timers – a general internist with 25 years on our medical staff. His daddy had been chief of staff a generation earlier. The note read: ‘I was brought up to hate XYZ hospital across town. But if you don’t start a hospitalist program, I’m gonna hold my nose and start admitting my patients there.’”

Having a few PCPs become hospitalists doesn’t really shrink the primary care workforce. How’s that? Imagine a group of 7 busy PCPs, each coming to the hospital every day. Now one of them becomes a hospitalist, and the other six no longer do hospital rounds. You haven’t really “lost” a PCP; the work has just been redistributed, since the remaining PCPs no longer have the inefficiency of schlepping to the hospital, each to see 1-2 patients. The others can grow their outpatient practice by at least the equivalent of the one hospitalist (or they can sleep in).

But we may have reached the point that primary care has become so unattractive for so many docs that the migration to hospital medicine truly is contributing to the PCP shortage. I received this note last week from a faculty colleague of mine at UCSF:

Now that the hospitalist movement has trickled down to even the smallest hospitals, outstanding primary care internists are leaving primary care practice in droves to become hospitalists. I am dismayed to find out in the last week that all three of my 85-year-old parents’ doctors are becoming hospitalists… their two internists will be hospitalists at the local hospital of 25 beds (yes, very small town on the Idaho-Washington border), and my father’s neurologist… is moving from neurology outpatient practice to a 125-bed hospital in the nearby city of ~200,000. I have no idea where I’m going to find good primary care doctors for them. Of course, should they be hospitalized, I know they will get good care!

Primary care physicians have an incredibly difficult job: trying to magically (in 15 minute visits) see complex, elderly patients with multiple medical problems, reconcile paper bags-full of medicines, and sort through stacks of Internet printouts that patients now helpfully (?) cart along. As I mentioned recently, one study found that just following recommended preventive practices would take a PCP nearly 8 hours a day, before dealing with any new or acute problems. All for a salary of about $160,000/year (less than half that of the average radiologist), low prestige, and a constant stream of bureaucratic and paperwork hassles. Any wonder that today’s medical students, no longer constrained by the “smart kids go into internal medicine” pablum of my training era, are flocking to the RAP specialties (radiology, anesthesia, pathology) in droves?

Can this get fixed? Since much of the crisis relates to changes in the payment system (not all, but much), and since physician payment is a zero-sum game, increasing compensation for PCPs will depend on significant cuts to highly-paid procedural specialists. Not surprisingly, these group have hired great lobbyists, who will ensure that any cuts for their clients are relatively minor – which means that extra payments for PCPs will be mostly symbolic. Unlike hospital medicine, there is no “deep pocket” like a hospital that can recognize the value of the field and throw some money into the pot (exception: primary care docs in large multispecialty systems like Kaiser-Permanente and the Palo Alto Medical Clinic, where money can be moved around to support the primary care workforce). Yes, some PCPs will find extra money in the purses of wealthy Nordstrom shoppers (i.e., concierge practices), but that’ll just work in a few tony zip codes and for a few well coifed super-docs. The bottom line: primary care is withering on the vine, and I see nothing very hopeful on the horizon (no, not even the Patient-Centered Medical Home, a topic I’ll return to in a later post).

In my judgment, three things will need to happen to resurrect primary care:

Congressmen will need to be unable to find a PCP for themselves or their parents;

All the primary care fields will need to band together and lobby with a single voice, rather than as general internists versus family physicians (Historical note: when there was even a whiff of a national nursing shortage, we never heard about critical care nurses or ward nurses or OR nurses. We heard the entire nursing profession shout, with a single voice, “There aren’t enough nurses, and people will die because of it!”);

Managed care will be resurrected, in some new garb, to deal with healthcare inflation. Two guarantees: It won’t be called “managed care” this time, and the inevitable strategy to promote primary care over more expensive specialist care won’t be called “gatekeeping”.

When all these things happen – probably before hell freezes over, but only because of Global Warming-induced delays – then expect the resources and political energy to remake primary care into an appealing field. Until then, medical students and residents will continue to vote with their feet, and many internal medicine, pediatric, and family medicine grads interested in generalism will find hospital medicine to be a more attractive generalist path. The way to fix that is not by trashing hospital medicine – a rare generalist success story in medicine – but by continuing to work on making primary care viable again.

6 Responses to “Are Hospitalists Killing Primary Care?”

I am so sad to read this article. As a General Internal Medicine resident who graduated residency in 1993 (at the height of managed care), who became a hospital-based Internist for 3 years, then headed out to Outpatient medicine for 11 years and now back as a Hospitalist, you have hit every point. I think the death of outpatient general Internal Medicine is inevitable. Between Medicare cuts, very little respect from patients and specialized physicians, nurse practitioners and other mid level “providers”, most of us will find our way back into the hospital.

Outpatient primary care is definitely going the way of the dinosaurs. It’s very sad. In fact, of the 17 residents graduating from our residency program, 16 are taking hospitalist jobs. In our community, PCPs are really hurting… new patient waiting times can be as long as 2 months or PCPs are simply not taking new patients. Medicaid patients are simply denied.
I agree that hospitalism is not poaching the physicians but just providing another opportunity for Internal Medicine physicians. As Dr. Wachter said, PCPs and residents are voting with their feet. The real goal should be how to make primary care more attractive. Unfortunately, I’m not sure how this is going to fly as the PCPs have been trampled underfoot for some time now. Just look at the way Medicare sets up their payment system. Medical-decision making is so slanted towards procedures to the point of being a travesty. Good hard cerebral work does not seem to elicit higher rewards.
I really think what is going to end up happening is that hospitalists are going to have to adapt to the shortage of PCPs. The hospitals are going to have to set up outpatient clinics which the hospitalists will have to staff. I know this goes against what hospitalists are supposed to be doing, but what other option do we have at this point???

“…many internal medicine, pediatric, and family medicine grads interested in generalism will find hospital medicine to be a more attractive generalist path.”

Is the hospitalist specialty a really a “generalist path”? Hospitalized patients have entered a complex medical institution through the filter of a community or emergency room provider. Granted, hospitalist medicine is evolving to the point where hospitalists can concentrate on specific areas, such as palliative medicine, specific surgical sub-specialty co-management, et cetera. However this degree of possible specialization within hospital medicine does not necessarily mean that a hospitalist is well-characterized as a generalist.

The appeal of primary care is still continuity, longitudinal relationships with patients, and particularly in the case of family practice and Med-Peds providers the ability to appropriately triage, evaluate, and manage anybody that makes it through the door of the clinic. In the case of communities in which hospitalists are still not used, ditto the hospital. Now, that’s a generalist.

I dont feel primary care is being threatened by hospitalists. If anything, it enhances our ability(i am a fam doc)to provide more efficient office based medicine. To me, hospital work is way too much for a busy family practictioner. For those who feel threatened , i suppose they should consider retraining.

In my opinion, the solution is to provide financial incentives for becoming an outpatient generalist. With the escalating costs of medical education, medical education should be essentially free for those who become generalists, whether through Family Practice or Internal Medicine residencies.
My understanding of the Primary Care Scholars program is that a commitment is expected in the first year of medical school and that physicians have limited choices where they can practice. The way it should be, is that any medical student who chooses primary care at any time during medical training, should have loan forgiveness, free tuition and books, and should be able to choose where they will practice primary care.

Many of my classmates chose to become specialists for monetary reasons. Tuition was increased every year (in my case, from $29,000 my first year to $34,000 my fourth year). The out-of-state tuition at my med school (Penn State) is now approaching or has surpassed $40,000 a year. One of my favorite classmates, who did choose primary care (Med/Peds), was facing almost $250,000 dollars of debt at the start of his career, because he had to pay for his own undergrad education as well.

In addition, there need to be tax breaks for PCPs. I doubt that higher salaries or reimbursements for being a PCP are feasible (deserved, certainly, but not probable).
Like elementary school teachers, PCPs are a vital part of society. Like elementary school teachers, compensation must be in terms of making the job itself more desirable. Tax incentives for being a PCP (that increase the more years a physician does it), financial help with purchasing a first home, free medical school tuition, 8 weeks vacation a year, retirement benefits, these are ways to send the message that PCPs are needed and valued and to recruit medical students.
I recently graduated residency and became a Hospitalist because inpatient medicine was a better fit for my personality. However, I would certainly consider doing both (Hospitalist and outpatient medicine, though never during the same day), if an attractive enough job opportunity presented itself.
I could not agree with you more that Family Practice and Internal Medicine physicians who are PCPs should band together with one voice to make these changes. Any division between the two fields is minor and artificial.
As Hospitalists, we emphatically need to support our outpatient colleagues, because communication and emotional support between Hospitalists and PCPs is the key to excellent and optimal patient care.

Hi.
Fewer practitioners means more difficulty finding one to help you, or making an appointment with the one you already see. You can see that the smaller numbers of primary care doctors would have an impact on your ability to find one for your care.

There are two problems that contribute to the shortage: The low numbers of medical students who are choosing primary care as a specialty, and the increasing numbers of Baby Boomers who require more and more care as they age.